No one will feel the effects of the two-year budget passed by the New Hampshire House more, if it is enacted, than New Hampshire low-income residents who need help paying for, and accessing, health care.

The $15.36 billion FY 2026-27 budget passed by the House Thursday, April 10, cuts Gov. Kelly Ayotte’s $16 billion proposal by $643 million. It takes its deepest cut from the state Department of Health and Human Services — $269 million less than what was proposed by Ayotte in February. That includes $46 million in “back-of-budget” cuts, which aren’t specified in the state budget, but up to the agency head to come up with.

Many of those cuts are to Medicaid-related services; programs that provide health care support; resources and aid for the elderly, people with disabilities and those with low incomes. It eliminates programs designed to reduce health care costs overall in the state, and raises fees and costs for low-income people who receive Medicaid.

Ayotte said this week she hopes to work with the New Hampshire Senate, which has until June 5 to amend the House proposal, including cuts to mental health and disability services. Any disagreements between the House and Senate are worked out in a committee of conference, and the two-year budget goes into effect July 1.

The DHHS budget represents a massive share of the services the state provides to residents. It was $6.58 billion in the current fiscal biennium, representing 44% of the states’ expenditures.

House Republican budget leaders say the deep DHHS cuts from what Ayotte proposed are necessary to help close an $800,000 gap in their revenue projections as compared to the governor’s.

But those who opposed the budget said it goes too far, particularly when it comes to the state’s low-income residents.

“This budget will have devastating and long-lasting effects on the neediest in our state,” Rep. Mary Jane Wallner, D-Concord, said during the House Ways and Means approval process. Thursday’s vote was along party lines, with Democrats, in the minority, attempting to amend some of the cuts or fee increases. Most of those efforts were unsuccessful.

“If enacted, these proposed cuts will certainly have an impact on the lives, dignity, and futures of Granite Staters,” Kate Frey, vice president of advocacy at New Futures, said in an online statement Thursday. New Futures is a nonprofit that provides data and research on the health of New Hampshire children and families.

“The people who will feel these cuts the hardest are families struggling to make ends meet, older adults dependent on critical support services, people accessing treatment and recovery for substance use, health care providers reliant on state investment, and working individuals who rely on basic health care and economic opportunities,” Frey said.

Many of the biggest cuts, as well as fee hikes, are for families who receive Medicaid, which provides health care to people with low incomes, disabilities and the elderly. More than 182,000 New Hampshire residents, 13.4% of the state’s population, receive Medicaid, including 30.1% of children in the state and 64% of residents living in nursing homes, according to federal statistics. An additional 60,000 are included in the Granite Advantage Medicaid expansion program for residents between 19 and 64 who have a household income at or below 138% of the federal poverty guideline, which would be $21,597 for an individual.

Most Medicaid programs in New Hampshire are overseen by DHHS.

Among the House budget provisions affecting health care for low-income state residents:

• A required premium of 5% of income premium for Medicaid recipients above the federal poverty guideline. The premium would apply to households with no children that earn 100% or more of the federal poverty guideline ($15,650 for an individual, modified annual gross income, which includes all income, not just wages) and 255% or more of the federal poverty guideline for families with children (for instance, $67,957 of modified annual gross income for a three-member family). Those who oppose the premium characterize it as an income tax on those who can least afford it.
• An increase to the copay for prescription drugs for Medicaid recipients to $4 from the $1 and $2 most recipients paid. Those who oppose it say that it may seem like a small amount, but isn’t for many families who struggle to buy food or heat their house. Rep. Ken Weyler, R-Kingston, the chair of the House Finance Committee, said the increase will deter people who take advantage of the system by getting medication they don’t need.
• Cuts the Medicaid reimbursement rate by 3%, which means $52.5 million less to providers over the next two years, which will cause reductions in services and some health care providers shutting down, critics of the move have said.
• A $31.4 million reduction in funding for developmental disability services over two years, which would also reduce federal Medicaid matching funds, for a $62.8 million (6.4%) cut that would affect the developmental disability services waitlist for anyone needing increased aid, children aging out of school-based services and individuals with disabilities moving into the state.
• Suspends the WIC farmers market nutrition program, which provided $30 a month to WIC recipients to buy produce at farmers markets.
• Suspends congregate housing services for elderly residents who are eligible for Medicaid, but also increases the amount counties must contribute for long-term care for the elderly, from 2% to 3%, capped at a statewide total of $135.8 million in FY 2026 and $139.9 million in SFY 2027.
• Cuts $37.8 million over two years for community mental health, which would mean cuts in service or elimination of community mental health centers, the Rapid Response Team, and other initiatives to better serve people with mental health challenges, including to Mission Zero, a program that aims to provide mental health services that free up emergency room space used to board people suffering from mental illness.
• Changes to how the Alcohol Abuse Prevention and Treatment Fund is financed that limit the money to opioid-related programs.
• Eliminates the state’s family planning program, a $1.7 million cut, which provides contraception and prenatal services, as well as cancer screening and sexually transmitted disease prevention resources and testing.
• Suspending the State Loan Repayment Program for health care professionals, including dentists, who take jobs in underserved areas for 36 months or more, and in exchange the state pays a portion of their student loans. The program was created to incentivize health care work in areas that don’t have access to providers.
• Eliminating the Tobacco Cessation and Prevention Program, which is designed to reduce the prevalence and consumption of tobacco use, the top cause of preventable death in the state, as well as contributing to a large variety of health issues, including in children who breathe second-hand smoke. According to Quit NH, the state’s initiative to combat the effects of smoking, tobacco use costs New Hampshire $1.5 billion annually both directly and indirectly, including medical costs and lost productivity from illness related to it.
• Eliminating the New Hampshire Commission on Aging, which works to access federal Older American Act funds.
• Eliminating the Prescription Drug Affordability Board, which works to limit prescription drug costs.
• Eliminating four Dept. of Education positions that implement prevention and student wellness programming in schools (these are non-vacant positions).

Ayotte said before the vote that she plans to work with the Senate on getting some of what she proposed back into the budget, including funding for community mental health centers and the waiting list for services for people with developmental disabilities.

Adding to the outlook for Medicaid recipients and health care in New Hampshire is uncertainty about what will happen on the federal level. New Hampshire has a trigger law that, if federal funding for Medicaid drops below 90% of the program’s cost in the state, the Granite Advantage program will be terminated.

Congress is in the midst of considering changes to the Federal Medical Assistance Percentage that would require states to come up with a bigger percentage of their Medicaid share. Some of the proposals in the House budget had that in mind, including a shift to lower-cost medications and services. But the state would still have to come up with millions, which would likely include elimination of Granite Advantage, the expansion that provides Medicaid to more than 60,000 state residents.